Shoulder girdle and elbow conditions

Baseline care for these conditions is acetaminophen or NSAIDs and physical therapy chosen by phase of healing; the entries below note what differs - special tests, surgery, bracing, or splinting.

Acromioclavicular and sternoclavicular disorders

• Mechanism: a fall on the adducted shoulder or a collision with another individual, particularly during a sporting event

• Grades of injury

  • Type I
    • A minor sprain of the acromioclavicular ligament
    • No radiographic displacement
    • No tear of the acromioclavicular or coracoclavicular ligament
  • Type II
    • A tear of the acromioclavicular ligament, but not the coracoclavicular ligaments
    • Less than 25% increase in the coracoclavicular interspace
  • Type III
    • Tears of both the acromioclavicular and coracoclavicular ligaments
    • 25% to 100% displacement of the clavicle
  • Type IV
    • Tears of both the acromioclavicular and coracoclavicular ligaments
    • Posterior displacement of the distal clavicle into the trapezius fascia

• Symptoms

  • Pain at the top of the shoulder, which may worsen when moving the arm
  • Swelling, bruising, or tenderness over the joint
  • Limited range of motion in the shoulder
  • A bump or deformity where the clavicle or scapula has moved
  • A crunching or grinding sound when moving the arm
  • The collarbone may appear to move upward
  • The shoulder may appear to droop

• Diagnosis

  • Clinical presentation
  • Subjective statement of the mechanism of injury
  • X-ray

• Medical management

  • Types I-II: nonoperative (sling, rehab); type III: individualized, often nonoperative; type IV (and the rarer higher grades not covered here): typically surgical reduction and stabilization

• Physical therapy management

  • Sling during the acute phase to avoid shoulder elevation
  • Functional training and strengthening of muscles surrounding the joint
  • Manual therapy to the acromioclavicular or coracoclavicular ligament as appropriate

Proximal humeral fracture

• Mechanism: a fall on an outstretched arm or a motor vehicle accident

• Most are stable, minimally displaced fractures that do not require surgery; displaced fractures may need surgical fixation

• Symptoms

  • Intense shoulder pain
  • Swelling and bruising
  • Difficulty moving the arm

• Diagnosis

  • Clinical presentation
  • Subjective statement
  • X-ray

• Physical therapy interventions

  • Early passive range of motion to decrease range of motion restrictions
  • Non-weight-bearing early per physician recommendations
  • Eventual active range of motion, strengthening, and coordination activities initiated once medically cleared

Distal humeral fracture

• Mechanism: trauma that fractures the distal humerus

• Supracondylar fractures need immediate neurovascular screening: extension type (posterior displacement, most common) risks the brachial artery and median/anterior interosseous nerve with posterolateral displacement, or the radial nerve with posteromedial displacement - brachial artery injury causes pulselessness and can progress to Volkmann’s ischemic contracture; flexion type risks the ulnar nerve, affecting intrinsic hand function. In children, growth plate involvement can cause malunion.

• Displaced lateral condyle/epicondyle fractures need open reduction internal fixation (plates and screws) in adults, or percutaneous K-wire pinning (pins removed later) in skeletally immature patients

• Symptoms

  • Severe pain in the elbow area that may radiate to the forearm and shoulder.
  • Pronounced swelling around the elbow joint.
  • The elbow may appear bent or twisted.

• Diagnosis

  • Clinical presentation
  • X-ray

• Medical management

  • Surgery for internal fixation

• Physical therapy management

  • Aid in the management of symptoms during the inflammatory phase
  • After surgical intervention and the time of immobilization has concluded, mobility and strengthening begin per the plan of care

PTA role: If new neurovascular signs appear during treatment of a fracture or dislocation - pulselessness, new paresthesia, or paralysis distal to the injury - stop the intervention and notify the supervising PT immediately rather than modifying or progressing the plan of care. The PTA’s role is to collect data and report a change in status, not to make plan-of-care decisions.

Thoracic outlet syndrome

• Mechanism: compression of the neurovascular bundle that includes the brachial plexus, sympathetic trunk, subclavian artery and vein, and phrenic and vagus nerves due to alteration in thoracic outlet size

• Common areas of compression are:

  • Superior thoracic outlet
  • Scalene triangle
  • Between the clavicle and the first rib
  • Between the pectoralis minor and the thoracic wall

• Symptoms

  • Pain in the neck, shoulder, arm, or hand
  • Pain that worsens with certain activities, such as overhead reaching or holding objects
  • Numbness, tingling, or burning sensations in the arm, hand, or fingers
  • Symptoms may be worse at night or after prolonged activity
  • Weakness in the arm, hand, or grip
  • Swelling in the arm or hand
  • Coldness or cyanosis in the fingers

• Diagnosis

  • Clinical examination
    • Special tests
      • Adson’s test
      • Roos test
      • Wright test
      • Costoclavicular test
  • X-ray
  • MRI

• Medical management

  • Surgical removal of cervical rib as indicated
  • Surgical release of the scalenes as indicated

• Physical therapy management

  • Interventions vary based on the cause of thoracic outlet syndrome
  • Postural re-education
  • Joint mobility and strengthening as appropriate

Upper and lower crossed syndromes

Janda described two postural patterns named for the X their muscles form when drawn on the body: a line joining the tight muscles at the front and back crosses a line joining the weak muscles at the front and back.

Feature	Upper crossed syndrome	Lower crossed syndrome
Tight	Upper trapezius, levator scapulae, pectoralis major and minor (also suboccipitals, SCM and scalenes)	Lumbar erector spinae and hip flexors (iliopsoas, rectus femoris)
Weak	Deep cervical flexors, middle and lower trapezius, rhomboids, serratus anterior	Deep abdominals, gluteus maximus and medius
Posture	Forward head, rounded and elevated shoulders, increased thoracic kyphosis, scapular winging	Anterior pelvic tilt, increased lumbar lordosis

Upper crossed syndrome is common in office and computer workers. The plan of care stretches the tight muscles (for example, a doorway pectoral stretch) and strengthens the weak ones (chin tucks for the deep cervical flexors, prone exercises for the middle and lower trapezius, serratus anterior strengthening), with posture training and workstation changes such as screen height and regular breaks. For lower crossed syndrome, the hip flexors and lumbar extensors are stretched and the abdominals and gluteals strengthened.

The crossed syndromes are a clinical model: corrective exercise reliably improves measured posture, but its benefits for pain and function are less consistent.

Contrasting elbow conditions

Medial epicondylitis, lateral epicondylitis, and ulnar collateral ligament (UCL) injuries can all cause medial or lateral elbow pain with overlapping features - the table below lines up what distinguishes each one, including which special test finding a PT’s evaluation documents for each.

Condition	Pain location	Tissue involved	Mechanism	Provoking test	PT focus
Medial epicondylitis (golfer’s elbow)	Medial elbow at the epicondyle, may radiate into the forearm; ring and little finger tingling suggests associated ulnar nerve irritation	Pronator teres and flexor carpi radialis tendons at the medial epicondyle	Repetitive forearm pronation and wrist flexion (overuse)	Pain at the medial epicondyle with passive forearm supination, elbow extension, and wrist extension	Activity modification, counterforce bracing, stretching, and progressive eccentric strengthening of the wrist flexors/pronators
Lateral epicondylitis (tennis elbow)	Lateral elbow, may spread into the forearm or wrist	Extensor carpi radialis brevis tendon at the lateral epicondyle	Repetitive wrist extension (overuse)	Cozen’s test: pain at the lateral epicondyle with resisted wrist extension, fist clenched, forearm pronated	Activity modification, counterforce bracing, stretching, and progressive eccentric strengthening of the wrist extensors
UCL injury	Medial elbow over the ligament, worse with valgus loading (the late cocking and acceleration phases of throwing)	Ulnar collateral ligament	Repetitive valgus stress (e.g., throwing)	Valgus stress test: pain or laxity with valgus force at 20-30 degrees of elbow flexion	Taping or bracing for support, graded return to valgus loading; a positive Tinel’s sign at the cubital tunnel points to concurrent ulnar neuritis rather than ligament laxity

Elbow dislocation

• Mechanism: trauma that forces the elbow out of its anatomical alignment

• Posterior dislocation is the most common

  • Posterolateral dislocation occurs as a result of hyperextension from a fall on an outstretched arm
  • Posterior dislocations commonly cause an avulsion fracture of the medial epicondyle

• Complete dislocation can disrupt all of the following structures

  • Lateral collateral ligament, anterior and posterior capsule, medial (ulnar) collateral ligament, brachialis muscle, and the common wrist flexor and extensor origins

• Symptoms

  • Intense pain at the elbow joint, especially during movement
  • The elbow may appear visibly out of place, with the forearm at an unnatural angle
  • The elbow may feel loose or like it is going to give way.
  • Difficulty or inability to bend, straighten, or rotate the elbow.
  • Swelling and bruising around the elbow joint.

• Diagnosis

  • Clinical presentation
  • X-ray

• Medical management

  • Reduction of dislocation

• Physical therapy management

  • Stable elbow (easily reduced and stays in place) - initial immobilization followed by therapy to assist with regaining range of motion and strength
  • Unstable elbow (elbow continues to dislocate even after reduction) - surgery indicated

Little League elbow

• Little League elbow (medial apophysitis) is an overuse injury of the growth plate on the inner side of the elbow (the medial epicondyle) in children, caused by repetitive throwing that pulls hard on the tendons and ligaments there